EMERGENCY WITHDRAWAL
Emergency WithdrawalEffective Suspension Date FORMCHECKBOX FORMCHECKBOX / FORMCHECKBOX FORMCHECKBOX / FORMCHECKBOX FORMCHECKBOX Deferred Comp Use OnlySection 1 – Participant Information (Please PRINT NAME EXACTLY as reported to your payroll office)Name (First, MI, Last) ___________________________________________________________ SSN* _______________________Street Address: ______________________________________________________ FORMCHECKBOX Male FORMCHECKBOX Female City: _________________________________________ State: _____ Zip: _____________ Date of Birth: _____ / _____ / _____Phone Numbers: Home (______)______________ Work (______)_________________Email Address: _______________________ Please check if this a FORMCHECKBOX Name Change FORMCHECKBOX Address ChangeDo you have an outstanding Deferred Compensation loan? FORMCHECKBOX NO FORMCHECKBOX YES*Your disclosure of your social security number or taxpayer identification number is required. Section 112.215 F.S. authorizes the creation of the State of Florida Deferred Compensation Plan, which is intended to qualify for tax deferral pursuant to 26 USC 457. Use of the identifying numbers is mandated by 26 USC 6109. Your social security number or taxpayer identification number will be used as an identifying number for purposes of federal tax law.Section 2 - Unforeseeable Emergency Categories Please check one or more of the following guidelines that pertains to you, your spouse or your dependent FORMCHECKBOX Out of Pocket Medical, or Funeral Expenses FORMCHECKBOX Loss of Salary Due to Termination, Illness, or Accident FORMCHECKBOX Loss of Child Support Payments to Support Dependant Child FORMCHECKBOX Entry of a Minor Relative, or Ward into the Participant’s Household FORMCHECKBOX Loss of Property Due to a Casualty FORMCHECKBOX Foreclosure or Eviction on Primary Residence FORMCHECKBOX Other Sudden and Unexpected Event pursuant to Section 1.38 or 5.05 of Form DFS-J3-1176Section 3 - Investment Provider (IP)Information Which IP(s) do you want to withdraw from? _______ _______ _______Gross amount to be withdrawn FORMCHECKBOX Full FORMCHECKBOX Partial $____________ .00Section 4 – Federal Income Tax InformationComplete attached W4 Form and return with completed UE Withdrawal Form. NOTICE: Unforeseeable Emergency withdrawals are paid in a lump sum. All lump sum payments are paid by the investment provider(s) and taxed at 10% unless otherwise indicated above. A request for an Unforeseeable Emergency Withdrawal will result in all contributions being suspended until reinstated by the participant. Date to restart your contribution: _____ / _____ / _____By signing this application, I hereby acknowledge the following:? I have exhausted all other sources available to pay the financial hardship described and the amount I requested is only the amount that I reasonably require to satisfy the emergency need.? My financial hardship cannot be relieved through reimbursement or compensation by insurance or otherwise; a loan or a financial hardship withdrawal from a 401(k) plan (if available); by liquidation of my assets, to the extent such liquidation would not itself cause severe financial hardship; or by cessation of deferrals under the Plan.? I have attached documentation supporting this request for an emergency withdrawal.? I understand that these funds are taxable to me in the year that I receive them.? Emergency Withdrawals are not an eligible Rollover distribution.__________________________________________________________________Participant SignatureDateThis request is: APPROVED DENIED________________________________________Authorized Deferred Compensation SignatureDatePlease fill out completely.Monthly IncomeParticipant Net Salary$_________________(attach a copy of current earnings statement)Spouses Net Salary__________________(attach a copy of current earnings statement)Investment Income__________________(Real Estate, Stocks, Bonds, etc.)Other Income__________________Child Support__________________Miscellaneous__________________Total Monthly Income$_________________Monthly Expenses (Not Payroll Deducted)Rent or Mortgage$__________________Automobile(s)___________________Utilities___________________Telephone___________________Loans___________________Credit/Charge Cards____________________________________________________________________________________________________________________________Insurance_________________________________________________________________________________________Groceries___________________Gasoline___________________Child Care or Support___________________Miscellaneous_________________________________________________________________________________________Total Monthly Expenses $_________________Net Overage/Shortage $ _________________AssetsCash:Checking Account$__________________Savings Account __________________Investments:403(B)/401/IRA/SEP _________________Stocks___________________Bonds___________________Mutual Funds___________________(excluding Deferred Compensation)Precious Metals___________________(gold, silver, etc.)Real Estate_____________________(current market value)Other Investments___________________Other AssetsAutomobile___________________(current market value)Other:____________________________________________________________Total Assets$__________________LiabilitiesHome Mortgage$__________________Mortgage on other___________________propertiesPersonal Notes_________________________________________________________________________________________Credit/Charge Cards______________________________________________________Automobile Loan(s)___________________Other Debts______________________________________________________Total Liabilities$__________________* Income and/or expenses may vary from month to month, therefore, please indicate the estimated average. ................
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